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Virtual Reality Games as an Adjunct in Improving Upper Limb Function and General Health among Stroke Survivors
虚拟现实游戏作为改善中风幸存者上肢功能和整体健康的辅助手段

Mohd Azzuan Ahmad , Devinder Kaur Ajit Singh ，, Nor Azlin Mohd Nordin ,
莫哈末阿祖安·艾哈迈德 ， Devinder Kaur 阿吉特·辛格 ， ， Nor Azlin Mohd Nordin ，Khor Hooi Nee and Norliza Ibrahim
许许妮 （Khor Hooi Nee） 和诺丽莎·易卜拉欣 （Norliza Ibrahim） 1 Physiotherapy Programme, Centre for Rehabilitation and Special Needs, Faculty of Health Sciences,
1 健康科学学院康复及特殊需要中心物理治疗课程Jalan Raja Muda Abdul Aziz, Universiti Kebangsaan Malaysia, Kuala Lumpur 50300, Malaysia;
Jalan Raja Muda Abdul Aziz， 马来西亚国民大学， 吉隆坡 50300， 马来西亚;azzuanahmad@ukm.edu.my (M.A.A.); norazlin8@gmail.com (N.A.M.N.); khorhn90@gmail.com (K.H.N.)
azzuanahmad@ukm.edu.my （文学硕士）;norazlin8@gmail.com （N.A.M.N.）;khorhn90@gmail.com （K.H.N.）2 Physiotherapy Programme, Center for Healthy Ageing & Wellness, Faculty of Health Sciences,
2 物理治疗项目，健康老龄化与健康中心，健康科学学院，Jalan Raja Muda Abdul Aziz, Universiti Kebangsaan Malaysia, Kuala Lumpur 50300, Malaysia
Jalan Raja Muda Abdul Aziz， 马来西亚国民大学， 吉隆坡 50300， 马来西亚3 Physiotherapy Unit, Department of Medical Rehabilitation Services, Hospital Canselor Tuanku Muhriz,
3 Canselor Tuanku Muhriz 医院医疗康复服务部物理治疗科，Kuala Lumpur 56000, Malaysia; lizaphysioppukm@gmail.com
马来西亚吉隆坡 56000;lizaphysioppukm@gmail.com* Correspondence: devinder@ukm.edu.my; Tel.: +603-9289-7676; Fax: +603-2698-9506
* 通信方式：devinder@ukm.edu.my;电话：+603-9289-7676;传真：+603-2698-9506

Received: 11 September 2019; Accepted: 21 November 2019; Published: 16 December 2019
收稿日期： 2019-09-11;录用日期： 2019-11-21;出版日期：2019年12月16日

Abstract 抽象

Virtual reality (VR) games has the potential to improve patient outcomes in stroke rehabilitation. However, there is limited information on VR games as an adjunct to standard physiotherapy in improving upper limb function. This study involved 36 participants in both experimental and control groups with a mean age (SD) of 57 (8.20) and 63 (10.54) years, respectively. Outcome measures were the Fugl-Meyer assessment for upper extremities (FMA-UE), Wolf motor function test (WMFT), intrinsic motivation inventory (IMI), Lawton of instrumental activities of daily living (IADL), and stroke impact scale (SIS) assessed at pre-post intervention. The experimental group had 0.5 h of upper limb (UL) VR games with 1.5 h of standard physiotherapy, and the control group received 2 h of standard physiotherapy. The intervention for both groups was performed once a week for eight consecutive weeks. The results showed a significant time-group interaction effect for IMI , Lawton IADL and SIS domain of communication . A significant time effect was found in FMA-UE ( ), WMFT ( ), Lawton IADL , and SIS domains; strength, ADL and stroke recovery . These results indicated an improvement in UL motor ability, sensory function, instrumental ADL, and quality of life in both groups after eight weeks of intervention. However, no significant group effect on all the outcome measures was demonstrated. Thus, replacing a portion of standard physiotherapy time with VR games was equally effective in improving UL function and general health compared to receiving only standard physiotherapy among stroke survivors.
虚拟现实 （VR） 游戏有可能改善中风康复患者的预后。然而，关于 VR 游戏作为标准物理疗法的辅助手段在改善上肢功能方面的信息有限。这项研究涉及 36 名参与者，他们都参与了实验 和控制 平均年龄 （SD） 分别为 57 （8.20） 和 63 （10.54） 岁的组。结局指标是上肢 Fugl-Meyer 评估 （FMA-UE） 、 Wolf 运动功能测试 （WMFT） 、内在动机量表 （IMI） 、日常生活工具性活动劳顿 （IADL） 和中风影响量表 （SIS） 在干预前评估。实验组进行 0.5 h 的上肢 （UL） VR 游戏和 1.5 h 的标准物理治疗，对照组接受 2 h 的标准物理治疗。两组的干预均连续 8 周每周进行一次。结果表明 IMI 具有显著的时间互效应 、劳顿 IADL 和 SIS 通信域 .在 FMA-UE （ ）， WMFT （ ）， Lawton IADL 和 SIS 域;力量、ADL 和中风恢复 .这些结果表明，干预 8 周后，两组的 UL 运动能力、感觉功能、仪器 ADL 和生活质量都有所改善。然而，没有显著的 证明了对所有结局指标的组效应。因此，与中风幸存者仅接受标准物理治疗相比，用 VR 游戏代替部分标准物理治疗时间在改善 UL 功能和整体健康状况方面同样有效。

Keywords: physiotherapy; virtual reality games; upper limb; function; stroke
关键词：物理治疗;虚拟现实游戏;上肢;功能;中风

1. Introduction 1. 引言

Stroke is a leading cause of significant disability among adults globally [1]. Rehabilitation is of utmost importance with an increase in the number of stroke survivors [2]. Stroke rehabilitation requires a multidisciplinary approach, is long-term and challenging due to its complexity [3]. Recent evidence suggests that the extension of a stroke rehabilitation programme may lead to further improvement in function and quality of life among stroke survivors [3].
卒中是全球成人严重残疾的主要原因 [1]。随着卒中幸存者人数的增加，康复至关重要 [2]。中风康复需要多学科方法，由于其复杂性，是长期且具有挑战性的 [3]。最近的证据表明，中风康复计划的扩展可能会进一步改善中风幸存者的功能和生活质量 [3]。
Persistent upper limb (UL) dysfunction after a stroke is one of the most challenging issues in rehabilitation [4]. Increasing the dose of rehabilitation among stroke survivors may improve
卒中后持续性上肢 （UL） 功能障碍是康复中最具挑战性的问题之一 [4]。增加卒中幸存者的康复剂量可能会改善
outcomes, and one of the strategies includes performing self-administered exercises using VR games technology [4]. VR is a computer-assisted technology that can provide users with experiences of a simulated "real" environment [5]. VR technology has been used in rehabilitation in addition to standard physiotherapy, or as a preventive therapy [5]. VR-based rehabilitation also offers the capacity to individualise treatment needs while providing the standardisation of assessment and training protocols [5].
结果，其中一种策略包括使用 VR 游戏技术进行自我管理的练习 [4]。VR 是一种计算机辅助技术，可以为用户提供模拟的“真实”环境体验 [5]。除了标准物理治疗外，VR 技术还用于康复，或作为一种预防性治疗 [5]。基于 VR 的康复还提供了个性化治疗需求的能力，同时提供了评估和训练方案的标准化 [5]。
Earlier evidence suggested that VR technology can provide a unique medium whereby rehabilitation can be delivered in a functional and purposeful manner [6]. Moreover, VR technology-based rehabilitation can be readily graded and documented [6]. Other than that, stroke survivors can perform VR training at their home and the therapist can monitor from a distance, known as tele-rehabilitation [7]. Compliance towards treatment and rehabilitation is a vital factor to consider in stroke management [8]. Hence, VR rehabilitation has the potential to improve patient participation, enable intensive therapy and reduce demand on health care professionals [5-7].
早期的证据表明，VR 技术可以提供一种独特的媒介，从而以功能性和有目的性的方式提供康复 [6]。此外，基于 VR 技术的康复可以很容易地分级和记录 [6]。除此之外，中风幸存者可以在家中进行 VR 训练，治疗师可以从远处进行监测，称为远程康复 [7]。对治疗和康复的依从性是卒中管理中需要考虑的重要因素 [8]。因此，VR 康复有可能提高患者参与度，实现强化治疗并减少对医疗保健专业人员的需求 [5-7]。
In previous studies, VR games were shown to be effective in improving physical function among stroke survivors [9], balance and functional mobility in older adults [10,11], and upper limb reaction time in adults with physical disabilities [12]. However, balance and mobility issues were examined rather than upper limb function [9,11]. There is also limited information on VR games as an adjunct to standard physiotherapy. Moreover, previous evidence mainly demonstrates the effects of VR as a standalone intervention among stroke survivors [13,14]. For example, in a pilot crossover design study involving 14 participants with chronic stroke, VR game-assisted intervention was performed for for a duration of 2.5 weeks [14]. The results showed improved UL motor performance using the Fugl-Meyer assessment for upper extremities (FMA-UE) as the primary outcome measure. In our present study, we aimed to examine the effectiveness of VR games as an adjunct to standard physiotherapy in improving upper limb (UL) function and general health among stroke survivors.

2. Materials and Methods 2. 材料和方法

2.1. Participants 2.1. 参与者

The required sample size was calculated using the G-Power analysis program version 3.1.9.2 [15]. A total of 34 participants was suggested to observe a significant difference between two different groups within effect size 0.25 , significance level , and power 0.80 . Forty participants were recruited from Hospital Canselor Tuanku Muhriz (HCTM) in this clinical trial. The inclusion criteria were: (1) stroke survivors at least 6 months post-stroke to include those with chronic stroke, (2) aged 18 years and above, (3) the affected arm scored at least 4 out of 6 according to the motor assessment scale, and (4) able to participate in the VR games training without limitation (presently with good health and no self-reported orthopaedic, medical, or painful conditions). Those with severe cognitive impairments (MMSE score less than 17) and taking any prescribed drugs that could potentially affect physical function and balance (such as corticosteroids, antipsychotics, or antidepressants) were excluded from the study.
Trained research assistants assisted by a physiotherapist from HCTM performed screening, the selection of participants, and supervised VR games training. Participants were informed about the study protocol and they signed a written informed consent before the start of the intervention. The study was approved by the Research and Ethics Committee of Universiti Kebangsaan Malaysia (UKM1.5.3.5/244/NN-110-2012) and registered with the Australian New Zealand Clinical Trials Registry (ANZCTR: ACTRN12618000725268).
在 HCTM 物理治疗师的协助下，训练有素的研究助理进行了筛选、参与者的选择和监督 VR 游戏培训。参与者被告知研究方案，并在干预开始前签署了书面知情同意书。该研究已获得马来西亚国民大学研究与伦理委员会 （UKM1.5.3.5/244/NN-110-2012） 的批准，并在澳大利亚新西兰临床试验注册处 （ANZCTR： ACTRN12618000725268） 注册。

2.2. Procedures 2.2. 程序

Forty eligible participants were allocated into two equal-size groups (experimental and control) by simple randomization. Four participants, two from each group, withdrew from the study due to unavoidable personal circumstances. Outcome measures were evaluated before and immediately on
completion of the 8 weeks of intervention. The experimental group had 0.5 h of VR games using Cy-Wee Z game controller and another 1.5 h of standard physiotherapy exercises. The control group continued with their 2 h of routine standard exercise therapy supervised by a physiotherapist. Each session comprised of stretching, strengthening, gait training, coordination, balance, and functional exercises, such as sit to stand and stair climbing. Both groups received eight therapy sessions, one per week for eight continuous weeks. An independent assessor carried out the measurement of all outcome measures at baseline (week 0) and eight weeks of intervention using standardised tools.

2.3. Virtual Reality Games
2.3. 虚拟现实游戏

In addition to 1.5 h of standard physiotherapy exercises, participants in the experimental group had VR games intervention for 0.5 h in the sitting position, supervised by a therapist. The single-user VR games comprised of a computer with 21 inches monitor and a Cy-Wee Z movement-based game controller. This game controller is equipped with accelerometer, gyroscope and magnetic sensors which enables display of free movement in 3-dimensional space and capacity to detect depth. A custom-made handlebar was incorporated into the Cy-Wee Z game controller to encourage bilateral upper limb movements.
除了 1.5 小时的标准物理治疗练习外，实验组的参与者在治疗师的监督下，以坐姿进行了 0.5 小时的 VR 游戏干预。单用户 VR 游戏由一台配备 21 英寸显示器的计算机和一个基于 Cy-Wee Z 运动的游戏控制器组成。该游戏控制器配备了加速度计、陀螺仪和磁性传感器，可以显示 3D 空间中的自由运动和深度检测能力。Cy-Wee Z 游戏控制器中集成了定制的车把，以鼓励双侧上肢运动。
The games selected consisted of various physical challenges such as stationary and moving target-hitting and sports related games. Examples of the games includes Mosquito Swat, Music Catch, ReBounce, Bejewelled, and Balloon Popping, 10-Pin Bowling, Air Hockey, Mah-Jong, and Solitaire. All of these games required large cursor movements in both horizontal and vertical directions to facilitate movements of the affected UL. Progress in the difficulty levels of the games was adjusted according to participants' individual achievements. Several measures were taken to ensure participants engagements during the VR intervention. The VR games intervention was conducted in a room with adequate space to avoid distraction from surroundings and allow unrestricted movements. An adjustable sound speaker was used for clear auditory feedback. The distance between the chair and monitor display was adjusted according to individual participants' preferences.
选择的游戏包括各种身体挑战，例如静止和移动目标击中以及与运动相关的游戏。游戏的示例包括 Mosquito Swat、Music Catch、ReBounce、Bejewelled 和 Balloon Popping、10 针保龄球、空气曲棍球、麻将和纸牌。所有这些游戏都需要在水平和垂直方向上大幅移动光标，以方便受影响的 UL 移动。游戏难度级别的进度根据参与者的个人成就进行调整。采取了多项措施来确保参与者在 VR 干预期间的参与度。VR 游戏干预在一个具有足够空间的房间内进行，以避免分散周围环境的注意力并允许不受限制的运动。可调节的扬声器用于清晰的听觉反馈。椅子和显示器之间的距离根据个人参与者的喜好进行调整。

2.4. Outcome Measures 2.4. 结果测量

The Fugl-Meyer assessment for upper extremities (FMA-UE) is a measure of UL motor and sensory impairment. FMA-UE commonly used in clinical and research and is one of the most common quantitative measures of motor impairment among stroke survivors [16,17]. Intra-rater reliability for the expert rater was high for the motor and sensory scores with a range of 0.95 to 1.0 [18].
上肢 Fugl-Meyer 评估 （FMA-UE） 是衡量 UL 运动和感觉障碍的指标。FMA-UE 常用于临床和研究，是卒中幸存者中最常见的运动障碍定量指标之一 [16,17]。专家评分者的运动和感觉评分的评分者内部信度很高，范围为 0.95-1.0 [18]。
The Wolf motor function test (WMFT) is a quantitative measure of UL motor ability, through timed and functional tasks, specifically for the evaluation of chronic stroke and traumatic brain injury patients [19]. The psychometric properties of the WMFT is excellent with an ICC score of 0.94 [20].
Wolf 运动功能测试 （WMFT） 是通过定时和功能任务对 UL 运动能力进行定量测量，专门用于评估慢性脑卒中和创伤性脑损伤患者 [19]。WMFT 的心理测量特性非常出色，ICC 评分为 0.94 [20]。
Intrinsic motivation inventory (IMI) is a multidimensional questionnaire to assess participants' subjective experiences related to activity [21]. IMI has been widely used in several types of research to evaluate the intrinsic motivation and self-regulation of participants [21]. The reliability (Cronbach's alpha) for IMI as a whole was 0.844 [22].
内在动机量表 （IMI） 是一种多维问卷，用于评估参与者与活动相关的主观体验 [21]。IMI 已广泛用于多种类型的研究，以评估参与者的内在动机和自我调节 [21]。IMI 的整体可靠性 （Cronbach's alpha） 为 0.844 [22]。
The Lawton of instrumental activities of daily living (IADL) scale assesses the more complex ADLs necessary for living in the community. There are eight domains of function measured by the instrument: an ability to use a telephone, shopping, food preparation, housekeeping, laundry, mode of transportation, responsibility for own medications, and the ability to handle finances [23]. Inter-rater reliability of Lawton IADL was 0.85 [23].
Lawton 日常生活工具活动 （IADL） 量表评估了在社区中生活所需的更复杂的 ADL。该仪器测量的功能有八个领域：使用电话的能力、购物、食物准备、家政、洗衣、交通方式、对自己药物的责任以及处理财务的能力[23]。Lawton IADL 的评分者间信度为 0.85 [23]。
The stroke impact scale (SIS) is a stroke-specific and self-report questionnaire designed to evaluate disability and quality of life (QOL) after stroke [24]. The internal consistency of the SIS is excellent with Cronbach's alpha values ranging from 0.80 to 0.95 [24].
脑卒中影响量表（stroke impact scale， SIS）是一份针对脑卒中的特异性自我报告问卷，旨在评估脑卒中的残疾和生活质量（quality of life， QOL）[24]。SIS 的内部一致性非常好，Cronbach α 值范围为 0.80 至 0.95 [24]。

2.5. Statistical Analysis
2.5. 统计分析

Data were analysed using Statistic Product for Statistical Solutions (SPSS) version 19.0 (SPSS Inc. Chicago, IL, USA). ANCOVA and Chi-Square tests were used to tests the effect of age, post-stroke
duration, and the affected side of stroke as dependent variables. The main effects of time, group, and time-group interaction were analysed using repeated measure ANOVA. The significance level was set at .

3. Results 3. 结果

Thirty-six participants (18 experimental and 18 control) completed the study. Figure 1 shows the flow of the participants through the study. Participants' demographic data at baseline are presented in Table 1. ANCOVA and Chi-Square tests demonstrated that there was no significant effect of age, post-stroke duration, and the affected side of stroke as dependent variables. The results of all outcome measures at baseline and eight weeks post-intervention are listed in Table 2. Repeated measure ANOVA showed a significant effect of time in FMA-UE , WMFT , Lawton IADL , and the SIS domains of strength , ADL p2 , and stroke recovery p2 . However, no significant effect of group on all the outcome measures was found. The results indicate that both groups (experimental and control) improved UL physical function (motor and sensory), instrumental ADL, and QOL after eight weeks of intervention.
Figure 1. Flow chart of the study with number of participants. FMA-UE, Fugl-Meyer assessment for upper extremities; WMFT, Wolf motor function test; IMI, intrinsic motivation inventory; IADL, instrumental activities of daily living; SIS, stroke impact scale; VR, virtual reality; SPSS, statistic product for statistical solutions.
图 1.包含参与者人数的研究流程图。FMA-UE，上肢的 Fugl-Meyer 评估;WMFT，Wolf 运动功能测试;IMI，内在动机量表;IADL，日常生活的工具性活动;SIS，卒中影响量表;VR，虚拟现实;SPSS，统计解的统计产品。
Table 1. Baseline characteristics of participants.
表 1.参与者的基线特征。
Variable 变量
 实验的
Experimental
 控制
Control
Analysis of Covariance 协方差分析
Mean (SD) 平均值 （SD） Mean (SD) 平均值 （SD） -Values
-值
Gender (male/female) 性别 （男/女）
Age (years) 年龄 （岁） 0.07
Post stroke duration (months)
卒中后持续时间（月）		 0.93
Affected side (left/right)
患侧（左/右）		 0.50
All data as mean (standard deviation) with a -value for ANCOVA except for affected side (left/right) with -value for Chi-squared test. Statistically significant, .
所有数据均为平均值（标准差），ANCOVA 为 -值，但患侧（左/右）为 卡方检验为 -value。 具有统计显著性 .
Table 2. Main effect of time, group, and time-group interaction of the interventions on the outcome measures.
表 2.干预措施的时间、组和时间组相互作用对结局测量的主要影响。
Parameters 参数 Study Group 学习小组 Analysis of Covariance ( -Values)
协方差分析 （ -Values）
 实验均值 （SD）
Experimental
Mean (SD)
 控制均值 （SD）
Control
Mean (SD)
 时间
Time
 群
Group
 互动
Interaction
FMA-UE
Week 0 第 0 周 57.44 (10.17) 56.50 (8.18) 0.001 * 0.50 0.23
Week 8 第 8 周 65.94 (7.57) 63.22 (6.98) (0.76)
WMFT
Week 0 第 0 周 46.00 (10.99) 44.11 (7.64) 0.001 * 0.38 0.17
Week 8 第 8 周 53.61 (10.35) 50.05 (7.55) (0.05)
IMI
Week 0 第 0 周 126.94 (11.40) 118.22 (8.35) 0.16 0.14 0.001 *
Week 8 第 8 周 120.50 (10.00) 120.50 (8.37)
Lawton IADL 劳顿 IADL
Week 0 第 0 周 4.28 (2.22) 2.78 (1.00) 0.77 0.01 *
Week 8 第 8 周 4.56 (1.98) 3.00 (1.03)
SIS domains SIS 域
Strength 强度 0.00 * 1.00 0.16
Week 0 第 0 周 57.29 (15.93) 63.54 (12.91) (0.06)
Week 8 第 8 周 62.50 (11.94) 68.75 (13.89)
Week 0 第 0 周
Week 8 第 8 周
Emotion 情感 0.78 0.57 0.34
Week 0 第 0 周
Week 8 第 8 周
Week 0 第 0 周 94.84 (8.85) 84.92 (17.70)
Week 8 第 8 周 95.64 (9.05) 86.91 (14.13)
ADL/IADL
Week 0 第 0 周 84.32 (12.05) 77.41 (11.11)
0.67
0.06
Week 8 第 8 周 86.68 (10.31) 79.23 (11.11)
Mobility 流动性
Week 0 第 0 周 85.34 (10.52) 80.86 (15.06)
0.06
0.82
0.25
Week 8 第 8 周 87.50 (6.95) 82.56 (15.12)
Hand function 手部功能
Week 0 第 0 周 68.61 (27.64) 66.11 (22.59)
0.77
0.77
0.79
Week 8 第 8 周 68.61 (27.80) 66.67 (22.10)
Social 社会的
Week 0 第 0 周
0.74
0.19
0.45
Week 8 第 8 周
Stroke recovery 中风恢复
Week 0 第 0 周
0.001 *
0.45
0.00
0.09
Week 8 第 8 周 73.89 (10.37)
Values are presented as mean standard deviation. , partial eta squared; FMA-UE, Fugl-Meyer assessment for upper extremities; WMFT, Wolf motor function test; IMI, intrinsic motivation inventory; IADL, instrumental activities of daily living; SIS, stroke impact scale. Statistically significant, by repeated measure ANOVA.
值以平均 标准差表示。 ，部分 eta 平方;FMA-UE，上肢的 Fugl-Meyer 评估;WMFT，Wolf 运动功能测试;IMI，内在动机量表;IADL，日常生活的工具性活动;SIS，卒中影响量表。通过 重复测量方差分析具有统计显著 性。
Higher percentages of improvement were demonstrated in the experimental group compared to the control group for FMA-UE, WMFT, and several SIS domains, namely strength, memory and thinking, emotion, ADL/IADL, and mobility (Figure 2). Interestingly, there is no significant difference between the two interventions as shown by the main effect of group. This suggests that the experimental and control groups had similar outcomes after the intervention. Despite no overall difference between the two groups, the analysis of time-group interaction showed significant effects for IMI ( ; , Lawton IADL , and the SIS domain of communication ; ). These results indicate that the time course for the two intervention is significantly different for the three outcomes. The control group showed slightly more improvements in instrumental ADL, communication, and higher self-perceived positive experience measured using IMI (Figure 2).
与对照组相比，实验组在 FMA-UE 、 WMFT 和几个 SIS 领域（即力量、记忆和思维、情绪、ADL/IADL 和活动能力）方面的改善百分比更高（图 2）。有趣的是，从组的主效应可以看出，两种干预措施之间没有显着差异。这表明实验组和对照组在干预后结局相似。尽管两组之间总体上没有差异，但时间组相互作用的分析显示对 IMI （ ; 、Lawton IADL 和 SIS 通信 域; ）。这些结果表明，两种干预的时间进程对于三种结局有显著差异。对照组在使用 IMI 测量的工具性 ADL、沟通和更高的自我感知积极体验方面显示出略多的改善（图 2）。
Figure 2. Percentage of improvement for the outcome measures after eight weeks of intervention. FMA-UE, Fugl-Meyer assessment for upper extremities; WMFT, Wolf motor function test; IMI, intrinsic motivation inventory; IADL, instrumental activities of daily living; SIS, stroke impact scale.
图 2.干预 8 周后结局指标的改善百分比。FMA-UE，上肢的 Fugl-Meyer 评估;WMFT，Wolf 运动功能测试;IMI，内在动机量表;IADL，日常生活的工具性活动;SIS，卒中影响量表。

4. Discussion 4. 讨论

The objective of this study was to examine the effectiveness of VR games as an adjunct to standard physiotherapy in improving UL function and general health among stroke survivors. The results indicated that participants in both groups improved in their UL motor ability, sensory function, instrumental ADL, and quality of life after eight weeks of intervention.
本研究的目的是检查 VR 游戏作为标准物理疗法的辅助手段在改善中风幸存者 UL 功能和整体健康方面的有效性。结果表明，干预 8 周后，两组参与者的 UL 运动能力、感觉功能、乐器 ADL 和生活质量都有所改善。
Higher percentages of improvement were observed in the experimental group (added VR games to standard physiotherapy) compared to the control (only standard physiotherapy) group for FMA-UE, WMFT, and SIS domains of strength, emotion, ADL, mobility, memory, and thinking (Figure 2). However, no statistically significant difference between the two groups was found in all the outcome measures. These findings suggest that participants in the experimental group did not improve more than those in the control, and both interventions were equivalent in terms of effectiveness. This result supports the substitution of a portion of standard physiotherapy time with VR games among stroke survivors. It is noteworthy that VR games may be self-administered by patients, thus freeing therapist time for managing patients with more acute problems.
与对照组（仅标准物理治疗）相比，实验组（在标准物理治疗中加入 VR 游戏）在力量、情绪、ADL、活动能力、记忆和思维的 FMA-UE、WMFT 和 SIS 领域的改善百分比更高（图 2）。然而，在所有结局指标中，两组之间没有发现统计学上的显著差异。这些发现表明，实验组的参与者并没有比对照组的参与者改善更多，并且两种干预措施在有效性方面是相同的。这一结果支持中风幸存者用 VR 游戏代替部分标准物理治疗时间。值得注意的是，VR 游戏可以由患者自行管理，从而让治疗师腾出时间来管理患有更严重问题的患者。
Although both groups demonstrated similar outcomes in improving UL motor ability and sensory function, the experimental group showed a higher percentage of improvements (FMA-UE 15%, WMFT ) compared to the control (FMA-UE 12%, WMFT 13%). This is consistent with previous studies that showed improvements in UL motor and sensory function among stroke survivors following VR training as measured using FMA-UE and WMFT [14,25,26]. We used a similar model of the game
尽管两组在改善 UL 运动能力和感觉功能方面表现出相似的结果，但与对照组 （FMA-UE 12%， WMFT 13%） 相比，实验组显示出更高的改善百分比 （FMA-UE 15%， WMFT ）。这与之前的研究一致，这些研究显示，使用 FMA-UE 和 WMFT 测量的 VR 训练后卒中幸存者的 UL 运动和感觉功能有所改善 [14,25,26]。我们使用了类似的游戏模型
controller for VR games intervention as in the pilot study by Hijmans et al. [14]. The strength of our pre-post study with a matched control at baseline is the use of VR games as a substitution for a portion of standard physiotherapy treatment instead of using VR games on their own.
控制器，用于 VR 游戏干预，如 Hijmans 等人的试点研究 [14]。我们的前后研究在基线时具有匹配对照的优势在于使用 VR 游戏替代标准物理治疗的一部分，而不是单独使用 VR 游戏。
Similarly, Levin et al. [26] stated that two-dimensional video-capture VR training led to a significant improvement in WMFT scores compared to standard physiotherapy. In our study, the improvements in both groups can be explained by the theory of neuroplasticity. In theory, the repetitive task-orientated practice can provide more effective motor relearning for neuronal recovery following stroke [5]. As for VR games training, intensive cursor movements involving bilateral hands in various directions when playing the games could have led to the additional effort that further enhances neuronal recovery [5,7]. In our present study, a custom-made handlebar was incorporated to facilitate motor movements of the affected hand by using the non-affected hand. A similar method has been used in a previous study where the affected hand was bandaged to the game controller if the participant was unable to hold it effectively to achieve bilateral hand activities [13].
同样，Levin 等人 [26] 指出，与标准物理治疗相比，二维视频捕捉 VR 训练导致 WMFT 评分显着提高。在我们的研究中，两组的改善都可以用神经可塑性理论来解释。从理论上讲，重复的任务导向练习可以为中风后的神经元恢复提供更有效的运动再学习 [5]。至于 VR 游戏训练，玩游戏时双侧手向各个方向的密集光标移动可能会导致额外的努力，从而进一步增强神经元恢复 [5,7]。在我们目前的研究中，结合了一个定制的车把，以通过使用未受影响的手来促进受影响的手的运动。在之前的一项研究中使用了类似的方法，如果参与者无法有效地握住受影响的手以实现双侧手部活动，则将受影响的手包扎到游戏控制器上 [13]。
In our study, the improvement in instrumental ADL could be due to the nature of VR games that provided a continuous challenge to increase UL coordination and reaction time. The VR games training also required various repeated movements that resembled UL functional activities. Our study findings were in agreement with a previous study, which showed a significant improvement in instrumental ADL using a VR shopping task [27]. Improvement in instrumental ADL is vital in achieving independent living and an improved QOL among stroke survivors.
在我们的研究中，工具性 ADL 的改进可能是由于 VR 游戏的性质，它为增加 UL 协调和反应时间提供了持续的挑战。VR 游戏训练还需要各种类似于 UL 功能活动的重复动作。我们的研究结果与之前的一项研究一致，该研究显示使用 VR 购物任务的仪器 ADL 有显着改善 [27]。工具性 ADL 的改善对于实现独立生活和改善中风幸存者的 QOL 至关重要。
As for the improvement in SIS domain of communication with VR games, a similar finding was found using VR training for 30 min followed by 15 min of functional training such as using a phone and cutting with a knife [28]. Communication improvements among stroke survivors in our study could have been due to the indirect effect of engagement and immersion via VR games. However, further studies are required to explore the use of single and multi-user VR training in improving communication among stroke survivors.
至于 SIS 与 VR 游戏通信领域的改进，使用 VR 训练 30 分钟，然后进行 15 分钟的功能训练，例如使用电话和用刀切割，也发现了类似的发现 [28]。在我们的研究中，中风幸存者之间的沟通改善可能是由于通过 VR 游戏的参与和沉浸感的间接影响。然而，需要进一步的研究来探索使用单用户和多用户 VR 培训来改善中风幸存者之间的沟通。
Despite the unique attributes of VR games, which include fun and dynamic training [13,14], participants in the experiment showed a reduction in IMI score after eight weeks of the intervention (Figure 2). This finding was unexpected and suggests that participants in the experiment preferred standard physiotherapy rather than VR Cy-Wee Z training. In contrast to Hale et al. [13], the perceptions of stroke survivors were acceptable and potentially beneficial when using a VR games Cy-Wee Z game controller for UL rehabilitation. Generally, VR gaming-based rehabilitation was reported to be highly accepted with overall satisfaction among stroke survivors and healthy controls [29]. Among the possible reasons for our contradictory results may be the lack of availability of diverse and interesting games in VR Cy-Wee Z and participants who were contented with their current therapy. Further, we used an individual-based questionnaire compared to an in-depth interview and open-ended focus group discussions, which could have provided more insights about participants' perceptions [13].
尽管 VR 游戏具有独特的属性，包括有趣和动态训练 [13,14]，但实验参与者在干预 8 周后显示 IMI 评分降低（图 2）。这一发现是出乎意料的，表明实验参与者更喜欢标准物理治疗而不是 VR Cy-Wee Z 训练。与 Hale 等人 [13] 相比，当使用 VR 游戏 Cy-Wee Z 游戏控制器进行 UL 康复时，中风幸存者的看法是可以接受的，并且可能是有益的。一般来说，据报道，基于 VR 游戏的康复在卒中幸存者和健康对照者中被高度接受，总体满意度 [29]。我们相互矛盾的结果的可能原因之一可能是 VR Cy-Wee Z 中缺乏多样化和有趣的游戏，以及参与者对当前的治疗感到满意。此外，与深入访谈和开放式焦点小组讨论相比，我们使用了基于个体的问卷，这本可以提供更多关于参与者感知的见解 [13]。
One limitation of our study is related to the quasi-experimental design that limited the randomization of participants. However, both experimental and control groups were similar in terms of their demographic data at baseline. The short duration of VR games intervention ( 0.5 h of VR games once a week for eight weeks) may be considered as inadequate, and this could be one of the reasons for the non-significant effects of adding VR games to standard physiotherapy. Moreover, potential confounding factors, such as baseline stroke severity and subtypes, were not taken into account in our study as this information was not available. Further qualitative and quantitative research with a larger sample size and longer duration of intervention may be required to determine the effectiveness of VR games for UL rehabilitation among stroke survivors.
我们研究的一个局限性与限制参与者随机化的准实验设计有关。然而，实验组和对照组在基线时的人口统计数据方面相似。VR 游戏干预的持续时间短（每周一次 0.5 小时的 VR 游戏，持续八周）可能被认为是不够的，这可能是在标准物理治疗中加入 VR 游戏效果不显着的原因之一。此外，由于无法获得这些信息，我们的研究没有考虑潜在的混杂因素，例如基线卒中严重程度和亚型。可能需要具有更大样本量和更长干预持续时间的进一步定性和定量研究，以确定 VR 游戏对中风幸存者 UL 康复的有效性。

5. Conclusions 5. 结论

The integration of VR games as an adjunct to standard physiotherapy for UL stroke rehabilitation was demonstrated to be equally beneficial compared to standard physiotherapy on its own. The use of VR games in our study was not intended to replace the current rehabilitation. On the other hand, VR
事实证明，与单独的标准物理治疗相比，将 VR 游戏作为 UL 中风康复标准物理治疗的辅助手段同样有益。我们研究中使用 VR 游戏并不是为了取代当前的康复。另一方面，VR
games exercise can be used by patients at home to increase the dosage of exercise and self-management, reduce healthcare dependency, and as an adjunct to aid therapists in the challenging process of stroke rehabilitation.
患者可以在家中使用 Games Exercise 来增加运动和自我管理的剂量，减少对医疗保健的依赖，并作为辅助手段来帮助治疗师完成具有挑战性的中风康复过程。
Author Contributions: Conceptualization, D.K.A.S. and N.A.M.N.; Methodology, D.K.A.S., N.A.M.N. and M.A.A.; Formal Analysis, D.K.A.S., M.A.A. and K.H.N.; Investigation, M.A.A. and K.H.N.; Resources, N.I.; Data Curation, M.A.A. and K.H.N.; Writing-Original Draft Preparation, M.A.A. and K.H.N.; Writing-Review & Editing, D.K.A.S. and N.A.M.N.; Supervision, D.K.A.S.; Funding Acquisition, D.K.A.S.
作者贡献： 概念化、D.K.A.S. 和 N.A.M.N.;方法论、D.K.A.S.、N.A.M.N. 和 M.A.A.;形式分析、D.K.A.S.、M.A.A. 和 K.H.N.;调查，MAA 和 K.H.N.;资源，N.I.;数据管理、MAA 和 K.H.N.;写作 - 原始草稿准备，M.A.A. 和 K.H.N.;写作审查和编辑，D.K.A.S. 和 N.A.M.N.;监督，D.K.A.S.;资金收购，D.K.A.S.
Funding: Funding for this research was provided using a Grant from Universiti Kebangsaan Malaysia (UKM-KOMUNITI -004-2011).
资金： 这项研究的资金是使用马来西亚国民大学 （UKM-KOMUNITI -004-2011） 的赠款提供的。
Acknowledgments: We thank the participants and management of Physiotherapy Department in Hospital Canselor Tuanku Muhriz (HCTM) for their support and assistance rendered in the study.
致谢：我们感谢 Canselor Tuanku Muhriz 医院 （HCTM） 物理治疗科的参与者和管理层在研究中提供的支持和帮助。
Conflicts of Interest: The authors declare no conflict of interest.
利益冲突：作者声明没有利益冲突。

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